Citation Nr: 1613579 Decision Date: 04/04/16 Archive Date: 04/13/16 DOCKET NO. 09-50 405 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Pittsburgh, Pennsylvania THE ISSUE Entitlement to service connection for a left shoulder disability. REPRESENTATION Veteran represented by: The American Legion ATTORNEY FOR THE BOARD P. Lopez, Associate Counsel INTRODUCTION The Veteran served on active duty from September 1973 to September 1993. This matter comes before the Board of Veterans' Appeals (Board) on appeal from a February 2007 rating decision of the Department of Veterans Affairs (VA) Regional Office (RO) in St. Louis, Missouri. Jurisdiction is with the RO in Pittsburgh, Pennsylvania. The Board previously considered this matter in August 2014, at which time it remanded for further development, to include a VA examination. An appeal was also perfected on the issues of service connection for a right shoulder disability and residuals of a severed right Achilles tendon. Service connection for these issues was granted in a November 2014 rating decision. This was a full grant, and the Veteran did not appeal the downstream issues of the disability rating or effective date assigned. As such, they are not on appeal. The claims file is now entirely contained in VA's secure electronic processing systems, Virtual VA and Veterans Benefits Management System (VBMS). The appeal is REMANDED to the Agency of Original Jurisdiction (AOJ). VA will notify the appellant if further action is required. REMAND The Veteran initially claimed service connection for a bilateral shoulder disability. As stated in the introduction, the RO already granted service connection for right shoulder acromioclavicular (AC) joint arthritis in a November 2014 rating decision. The Veteran contends that his left shoulder disability is the result of heavy lifting and duty assignments while on active duty. See March 2016 appellate brief. For the left shoulder, an October 2014 VA examination shows a diagnosis of AC joint arthritis. The Veteran stated that he began to experience left shoulder symptoms in the 1980s during service, but could not recall a specific trauma. He also indicated that he was a parachute rigger and did a lot of repetitive work, with a lot of carrying, lifting, and hoisting. The VA examiner opined that the Veteran's left shoulder disability was less likely as not related to service. The examiner's rationale was simply that there was no evidence of a left shoulder injury in service and that the earliest documented complaint of left shoulder issues was from 2003, ten years after separation from service. The Board finds that the examiner's opinion is inadequate for several reasons. First, the examiner did not consider the Veteran's lay statement that he began to experience left shoulder symptoms in the 1980s while he was still in service. In addition, the opinion lacks a reasoned medical explanation. Rather, it merely relies on the absence of corroborating evidence to rule out the occurrence of an in-service injury or a connection between in-service symptoms and the current disability. Thus, an adequate opinion is not of record. See Nieves-Rodriguez v. Peake, 22 Vet. App. 295 (2008); Stefl v. Nicholson, 21 Vet. App. 120 (2007). On remand, the VA examiner should provide an addendum opinion that shows adequate consideration of the evidence, to include the Veteran's reports of left shoulder symptoms in service and his contention that the current left shoulder disability is related to heavy lifting in service. The examiner should also consider whether the claimed left shoulder disability is secondary to the Veteran's now service-connected right shoulder disability, as the Veteran stated in the October 2014 VA examination that he ruses his left arm to compensate for his right shoulder limitations. Conclusions should be supported by a reasoned medical explanation. Accordingly, the case is REMANDED for the following action: 1. Forward the claims file to the individual who conducted the October 2014 VA examination, or another examiner if that examiner is unavailable, to provide an addendum opinion. (A full VA examination should not be scheduled unless it is deemed necessary by the examiner or otherwise required by the evidence.) Review of the claims file should be noted in the examination report. The examiner should respond to the following: Is the Veteran's current left shoulder disability at least as likely as not (probability of 50 percent or more) related to service? If not, is the left shoulder disability at least as likely as not proximately due to his service-connected right shoulder disability? If not, then is it at least as likely as not that the left shoulder disability has been aggravated (permanently worsened beyond it natural progression) by his service-connected right shoulder disability? If aggravation is found, the examiner should also state, to the extent possible, the baseline level of disability prior to aggravation. This may be ascertained by the medical evidence of record and also by the Veteran's statements as to the nature, severity, and frequency of his observable symptoms over time. The examiner must consider lay statements from the Veteran, in particular, his reports that he began to experience left shoulder symptoms in the 1980s during service and that he uses his left arm to compensate for the limitations of his service-connected right shoulder. If the examiner rejects the Veteran's reports, he or she must provide a reason for doing so. The Veteran's statements may not be rejected due solely to an absence of contemporaneous or corroborating medical evidence, although this may be considered with the other evidence of record. The examiner must provide a clear medical rationale for any opinion offered. This rationale must show adequate consideration of all pertinent lay or medical evidence, to include the Veteran's contention that his left shoulder disability is related to heavy lifting in service. If an opinion cannot be offered without resort to speculation, he or she should explain why and state what additional evidence, if any, would be required to offer an opinion. 2. If any benefit sought on appeal remains denied, issue a supplemental statement of the case. Then, return the case to the Board, if otherwise in order. The Veteran has the right to submit additional evidence and argument on the matter the Board has remanded. Kutscherousky v. West, 12 Vet. App. 369 (1999). All claims remanded for additional development or other appropriate action must be handled expeditiously. See 38 U.S.C.A. §§ 5109B, 7112 (West 2014). _________________________________________________ Eric S. Leboff Veterans Law Judge, Board of Veterans' Appeals Under 38 U.S.C.A. § 7252 (West 2014), only a decision of the Board of Veterans' Appeals is appealable to the United States Court of Appeals for Veterans Claims. This remand is in the nature of a preliminary order and does not constitute a decision of the Board on the merits of your appeal. 38 C.F.R. § 20.1100(b) (2015).